Obstrução lacrimal pós-tratamento oncológico: revisão de literatura / Lacrimal drainage system obstruction after cancer treatment: a literature review

RESUMO A obstrução de via lacrimal é uma possível complicação decorrente de tratamentos oncológicos sistêmicos e locais. A epífora crônica gera grande impacto na qualidade de vida desses pacientes, e, como a fibrose terminal da via lacrimal pode necessitar de procedimentos complexos para sua resolução, é importante estarmos atentos a esse efeito adverso, com o objetivo de reconhecê-lo e tratá-lo precocemente, ou mesmo preveni-lo. Nesta revisão da literatura, os autores analisam todos os agentes quimioterápicos e radioterápicos associados à obstrução lacrimal e descrevem os mecanismos, a frequência, os tratamentos e a profilaxia. Os tratamentos oncológicos associados à obstrução lacrimal foram: radioterapia em cabeça e pescoço (dosagem acima de 45 a 75Gy), radioiodoterapia (dosagem acima de 150mCi) e quimioterapia com 5-FU, S-1, capecitabine e docetaxel. A obstrução lacrimal pode ser irreversível, e a intubação profilática das vias lacrimais é uma possibilidade descrita de tratamento profilático em casos de radioterapia e uso do 5-FU, S-1 e docetaxel. O tratamento cirúrgico de todos os casos é a dacriocistorrinostomia.

ABSTRACT Lacrimal duct obstruction can be a side effect of systemic and/or local cancer treatments. Chronic epiphora has a great impact on the quality of life of oncological patients. Since terminal fibrosis of the lacrimal system may require complex procedures, it is important to be aware of this adverse effect in order to recognize and treat it, or even prevent it. A literature review was performed to identify all types of systemic cancer treatment associated with lacrimal obstruction and to describe the mechanisms, frequency, treatment, and prophylaxis. The oncological treatments associated with lacrimal obstruction were head and neck radiotherapy (dosage above 45-75 Gy), radioiodine therapy (dosage above 150 mCi), and chemotherapy with 5-FU, S-1, Capecitabine and Docetaxel. Depending on the dose, this complication may be irreversible. Prophylactic intubation of the lacrimal system is an option for prophylaxis in cases of radiotherapy, use of 5-FU, S-1, and Docetaxel. Final surgical treatment is dacryocystorhinostomy.

Efficacy of mitomycin C in modified transcanalicular diode laser dacryocystorhinostomy / Eficácia da mitomicina C na dacriocistorrinostomia transcanalicular com laser diodo modificada

ABSTRACT Objective: To evaluate the efficacy of mitomycin C in anatomical and functional success after modified transcanalicular diode laser dacryocystorhinostomy. Methods: A prospective, double-blinded, randomized placebo-controlled study compared the effect of topical mitomycin C on modified transcanalicular diode laser dacryocystorhinostomy. Group 1 had modified transcanalicular diode laser dacryocystorhinostomy with topical saline, while Group 2 had modified transcanalicular diode laser dacryocystorhinostomy with topical mitomycin C. Success was defined as anatomical patency and relief of symptoms at the end of 6 months. Results: Six months after surgery, Group 1 (30 patients) showed anatomical and functional success rates of 86.7% and 83.3%, respectively. Group 2 (32 patients) showed anatomical and functional success rates of 87.5% and 84.3%, respectively. There was no statistically significant difference between the groups 1 and 2 (p = 1.000). Conclusion: The use of mitomycin C did not improve the anatomical and functional success rates of modified transcanalicular diode laser dacryocystorhinostomy compared to placebo.

RESUMO Objetivo: Avaliar a eficácia da mitomicina C no sucesso anatômico e funcional após dacriocistorrinostomia transcanalicular com laser de diodo. Métodos: Estudo prospectivo, duplo-cego, randomizado e controlado por placebo. Comparou o efeito da mitomicina C tópica na dacriocistorrinostomia transcanalicular com laser de diodo. No Grupo 1, foi utilizada apenas solução salina tópica, enquanto no Grupo 2 foi utilizada mitomicina C tópica. O sucesso foi definido como permeabilidade da via lacrimal e alívio dos sintomas ao final de 6 meses. Resultados: Seis meses após a cirurgia, o Grupo 1 (30 pacientes) apresentou taxas de sucesso anatômico e funcional de 86,7% e 83,3%, respectivamente. O Grupo 2 (32 pacientes) apresentou taxas de sucesso anatômico e funcional de 87,5% e 84,3%, respectivamente. Não houve diferença estatística significante entre os Grupos 1 e 2 (p=1,000). Conclusão: O uso de mitomicina C não melhora as taxas de sucesso anatômico e funcional do dacriocistorrinostomia transcanalicular com laser de diodo em comparação ao placebo.

Alpha-Adrenergic Agonists Stimulate Fluid Secretion in Lacrimal Gland Ducts.

Purpose: The role of adrenergic innervation in the regulation of lacrimal gland (LG) ductal fluid secretion is unknown. The Aim of the present study was to investigate the effect of adrenergic stimulation on fluid secretion in isolated LG duct segments and to study the underlying intracellular mechanisms. Methods: Fluid secretion of isolated mouse LG ducts was measured using video-microscopy. Effect of various adrenergic agonists (norepinephrine, phenylephrine, and isoproterenol) on fluid secretion as well as inhibitory effects of specific antagonists on adrenergic agonist-stimulated secretory response were analyzed. Changes in intracellular Ca2+ level [Ca2+i] were investigated with microfluorometry. Results: Both norepinephrine and phenylephrine initiated a rapid and robust fluid secretory response, whereas isoproterenol did not cause any secretion. Phenylephrine-induced secretion was completely blocked by α1D-adrenergic receptor blocker BMY-7378. The endothelial nitric oxide synthase (eNOS) inhibitor L-NAME or guanylyl cyclase inhibitor ODQ reduced but not completely abolished the phenylephrine-induced fluid secretion, whereas co-administration of Ca2+-chelator BAPTA-AM resulted in a complete blockade. Phenylephrine stimulation induced a small, but statistically significant elevation in [\(Ca_i^{2 + }\)]. Conclusions: Our results prove the direct role of α1-adrenergic stimulation on LG ductal fluid secretion. Lack of isoproterenol-induced fluid secretory response suggests the absence of ß-receptor mediated pathway in mouse LG ducts. Complete blockade of phenylephrine-induced fluid secretion by BMY-7378 and predominant inhibition of the secretory response either by L-NAME or ODQ suggest that α-adrenergic agonists use the NO/cGMP pathway through α1D receptor. Ca2+ signaling independent from NO/cGMP pathway may also play an at least partial role in α-adrenergic induced ductal fluid secretion.

Primary tubercular dacryocystitis - a case report and review of 18 cases from the literature.

Tuberculosis is an airborne communicable disease primarily affecting lungs. Primary tuberculosis of the lacrimal sac is very rare. A 15-year-old girl presented with bilateral epiphora for 8 months. Examination revealed bilateral nasolacrimal duct obstruction. During dacryocystorhinostomy, bone over lacrimal sac was found partially eroded. Lacrimal sac was found filled with caseous white material. Biopsy from the lacrimal sac revealed tubercular granulomas. Patient improved after anti-tubercular therapy. Abbreviations: PCR: polymerase chain reaction; NAAT: nucleic acid amplification test.

Effects of ostium granulomas and intralesional steroid injections on the surgical outcome in endoscopic dacryocystorhinostomy.

PURPOSE: To determine the effect of granuloma formation in the ostium and intralesional steroid injections (ISIs) on the surgical outcome after endoscopic dacryocystorhinostomy (DCR) in patients with primary acquired nasolacrimal duct obstruction (PANDO). METHODS: One hundred and eighty-three cases involving 142 patients were enrolled. The ostium granulomas were classified according to their location relative to the internal common opening (superior, anterior, and posterior positions) and to the vicinity of the ostium (inner, edge, and extra types). If an ostium granuloma was observed during the follow-up and its size increased, ISIs were performed using 0.3 ml of 40 mg/ml triamcinolone acetonide. The surgical outcomes were compared between cases with and without ostium granulomas and also between each granuloma position and type. RESULTS: Ostium granulomas occurred in 71 (38.8%) of the 183 cases, and an ISI was applied in 65 cases with a mean of 2.1 injections. All of the granulomas regressed successfully after ISIs, with the success rate not differing between the cases with (85.9%) and without (83.9%) granuloma. There was no association between granuloma location and surgical outcome. However, the functional outcome was worse (60%) for inner granulomas (which are located within the ostial base) than for extra (87.8%) and edge (98%) granulomas. CONCLUSIONS: ISIs can be easily applied by a surgeon to help regress an ostium granuloma and improve the ostial patency after DCR. Inner ostium granulomas are associated with a worse functional outcome, and the initiation of an early corrective intervention such as an ISI should be considered.

Botulinum neurotoxin injection for the treatment of epiphora in nasolacrimal duct obstruction.

PURPOSE: Retrospective long-term study to evaluate the efficacy of botulinum neurotoxin A (BoNT/A) therapy for epiphora due to non-surgical nasolacrimal duct obstruction. INTRODUCTION: BoNT/A has been used successfully since 2000 in axillary hyperhidrosis to reduce secretory disorders. Some isolated cases of hyperlacrimation or crocodile tear syndrome have been treated on this basis. We used BoNT/A to decrease lacrimal secretion in cases of epiphora. METHODS: We reviewed the qualitative and quantitative degree of improvement of epiphora after botulinum neurotoxin injections in the palpebral lobe of the lacrimal gland, carried out in an ophthalmic centre between 2009 and 2016. Epiphora was graded using a questionnaire, Munk scores and Schirmer tests before and after injections. Severity of side effects was recorded. RESULTS: Twenty-seven palpebral lacrimal glands of twenty patients with epiphora, mean age 65±13, were treated with BoNT/A (Botox® or Xeomin®) from April 2009 to April 2016. The epiphora was induced by persistent nasolacrimal duct stenosis after surgical treatment. No conventional medical nor surgical treatment was effective at this time. The technique of injection, dilution and dosage were specific. We re-injected 14/27 cases on an as-needed basis, 7/27 cases three times, 3/27 cases four times, and 2/27 cases (same patient both glands) five times. The Schirmer test measured a decrease of lacrimal secretion in 24/27 (89%) lacrimal glands after neurotoxin injection. Side effects were ptosis in 4 cases and transient esotropia in 2 cases. The authors describe the injection techniques, the dosage, the volume and concentration of BoNT/A. CONCLUSION: Patients with epiphora can be treated effectively with BoNT/A to reduce lacrimal secretion of the principal lacrimal gland in its palpebral portion. Ninety percent of the patients were very satisfied, with few side effects (ptosis or mild diplopia lasting from 3 days to 3 weeks). More studies are needed to delineate which types of epiphora can be treated with BoNT/A.

Efficacy of adjunctive mitomycin C in transcanalicular diode laser dacryocystorhinostomy in different age groups.

PURPOSE: To evaluate the efficacy of adjunctive mitomycin C (MMC) in transcanalicular multidiode laser dacryocystorhinostomy (TCL-DCR) in different age groups. METHODS: Ninety-six eyes of 96 patients who underwent TCL-DCR for the treatment of nasolacrimal duct obstruction were included in this retrospective, comparative study. Patients were divided into 4 groups based on age and intraoperative use of MMC: group 1, TCL-DCR without MMC in the 20- to 44-year age group; group 2, TCL-DCR with MMC in the 20- to 44-year age group; group 3, TCL-DCR without MMC in the 45- to 76-year age group; group 4, TCL-DCR with MMC in the 45- to 76-year age group. The postoperative evaluation consisted of calculating and comparing the success rates between groups. RESULTS: Success rates at the final visit were 50% for group 1, 66.66% for group 2, 79.16% for group 3, and 84.61% for group 4. The differences between group 1 and group 4, and group 1 and group 3, were significant (p = 0.01 and p = 0.038, respectively). Logistic regression showed that age group had significant effect on success rate (p = 0.013). However, use of MMC had no significant effect on success rate (p = 0.23). CONCLUSIONS: The success rates of the TCL-DCR with MMC application were found to be higher than those of TCL-DCR without MMC in different age groups. However, the differences did not reach statistical significance. In addition, our study demonstrated that age may be a significant factor influencing the surgical outcome of TCL-DCR.

Correction of Tear Trough Deformity With a Cohesive Polydensified Matrix Hyaluronic Acid: A Case Series.

The tear trough or infraorbital hollow is a challenging area to treat, and only a few fillers are suitable for this delicate area. We report on a European case series of six subjects with mild to severe tear troughs who received treatment with cohesive polydensified matrix (CPM®) technology hyaluronic acid gel (Belotero® Balance). The product was injected as small depots (up to ten small boli 0.2 mL maximum each per side) at the supraperiosteal level along or below the orbital rim. Follow-up visits took place at 1, 3, 6, and 9 months after injection for independent evaluation of the clinical effect using the Merz Aesthetics Scale™ for infraorbital hollows and the Global Aesthetic Improvement Scale. Adverse events were also recorded. Mean hollowness scores were considerably improved compared with baseline in all subjects. In all women, the improvements remained throughout the 9-month study, with none reverting to their baseline score. Subjects' satisfaction with treatment was very high throughout the study, and all women stated that they would repeat treatment with the same product. The CPM hyaluronic acid gel was well tolerated. CPM hyaluronic acid gel is a safe and effective treatment for the tear trough area.

Botulinum toxin injection for the treatment of epiphora in lacrimal outflow obstruction.

PURPOSE: To describe our experience with the use of botulinum toxin (BoNTA) for the symptomatic treatment of lacrimal outflow obstruction. METHODS: We retrospectively reviewed the case notes of patients with epiphora due to lacrimal outflow obstruction who chose to have injections of botulinum toxin into the palpebral lobe of the lacrimal gland instead of surgery between 2009 and 2014. Epiphora was graded subjectively with Munk scores obtained before and after treatment as well as qualitative degree of improvement reported by the patients. Severity and duration of side effects were also noted. RESULTS: Seventeen patients (22 eyes, mean age 70.3, 4 males and 13 females) were identified. A mean of 3.5 (range; 1-10) injections of BoNTA (Botox, Allergan; 1.25-7.5 units) were given per eye. The mean interval between injections was 3.9 months (range 3-6). The mean Munk score (3.4, range 2-4) improved significantly after treatment to 1.6 (range: 0-3, P=0.0001 paired two-tailed t-test). Epiphora completely resolved in a fifth, improved by up to 60-90% in a half and only 'a little better' in a further fifth. Temporary bruising and diplopia (lasting 2 weeks) was reported in 12% (2/17). CONCLUSION: We report our outcomes for BoNTA to the palpebral lobe of the lacrimal gland in patients with lacrimal outflow obstruction epiphora seeking alternatives to surgery. This data provide further evidence for informed consent and for commissioning organisations considering the funding of this treatment.

Experimental evidence of fluid secretion of rabbit lacrimal gland duct epithelium.

PURPOSE: To investigate the osmotic water permeability of lacrimal gland (LG) duct epithelium by means of calculation of filtration permeability and to investigate LG ductal fluid secretion. METHODS: Experiments were performed on isolated rabbit LG duct segments maintained in short-term culture. Osmotically determined fluid movement or fluid secretion into the closed intraluminal space of cultured LG interlobular ducts was analyzed using video microscopic technique. RESULTS: The end of the LG ducts sealed after overnight incubation forming a closed luminal space. For the calculation of osmotic water permeability, ducts were initially perfused with isotonic HEPES buffered solution, and then with hypotonic HEPES buffered solution. Filtration permeability was calculated from the initial slope of the relative volume increase. Secretory responses to carbachol or to forskolin stimulation were also investigated. Forskolin stimulation resulted in a rapid and sustained secretory response in both solutions. Forskolin-stimulated fluid secretion was completely inhibited by bumetanide both in HEPES buffered and in HCO3 (-)/CO2 buffered solutions, suggesting the central role of Na(+)-K(+)-2Cl(-) cotransporter type 1 (NKCC1). Administration of carbachol initiated a rapid but short secretory response in both HEPES buffered and in HCO3 (-)/CO2 buffered solutions. Atropine completely abolished the carbachol-evoked fluid secretion. CONCLUSIONS: A new method was introduced to investigate LG duct function. Water permeability of rabbit LG duct epithelium was measured by calculating filtration permeability. Fluid secretion of LG duct cells induced by carbachol or forskolin was also demonstrated. These results provide calculated values of lacrimal duct osmotic permeability and direct experimental evidence of LG duct fluid secretion.

Circumostial injection of mitomycin C (COS-MMC) in external and endoscopic dacryocystorhinostomy: efficacy, safety profile, and outcomes.

PURPOSE: To evaluate the safety and efficacy of a new technique of circumostial mitomycin C (COS-MMC) injection in dacryocystorhinostomy (DCR) and to evaluate the outcomes. METHODS: A prospective, interventional consecutive case series involving 110 DCR surgeries performed over a period of 1 year using the COS-MMC technique were evaluated. All patients were operated by a single surgeon (M.J.A.). After fashioning of the mucosal flaps, all patients underwent an intramucosal injection of 0.02% MMC at 4 points (0.1 ml at each point) along the edges of the freshly created ostium. All patients were intubated, and stent removal was done at 12 weeks following the surgery. All patients underwent regular monitoring of the ostium to look for any complications. A minimum follow up of 6 months after stent removal was considered for final analysis. The outcome measures analyzed were anatomical and functional success, complications, and ostium. RESULTS: The mean age at presentation was 39.91 years. The diagnosis was primary acquired nasolacrimal duct obstruction in 60.9% (67/110) and persistent congenital nasolacrimal duct obstruction in 9.1% (10/110) of the patients. Twenty-six patients were known cases of failed DCR and underwent a revision DCR. Of the total patients, 19.1% (21/110) had a history of acute dacryocystitis, of which, 73% (80/110) of the surgeries were performed by an external approach and 27% (30/110) by endoscopic endonasal route. Anatomical success was noted in 97.3% (107/110) and functional success in 96.4% (106/110). All the 4 failures were due to cicatricial closure of the ostium. None of the patients were noted to have mucosal burns in the area where MMC was injected, and none of the Ostia showed any features of necrosis, infection, or any other complications. CONCLUSIONS: COS-MMC is a safe and effective adjunctive modality in DCR. No adverse effects on the ostium were noted. The technique appears to be promising for the success of cases with high risk of failures like revision DCR and traumatic secondary acquired nasolacrimal duct obstruction.

Dacryocystitis secondary to intranasal cocaine abuse: a case report and literature review.

PURPOSE: To report a case of dacryocystitis secondary to intranasal cocaine abuse and to review the literature on the effects of cocaine on sinus, nasal and lacrimal structures. METHODS: Case report and literature review. RESULTS: A 33-year-old male presented with unilateral epiphora and discharge, and clinical examination was consistent with dacryocystitis. He had a 2-year history of intranasal cocaine use. Computed tomography revealed extensive bilateral intranasal and sinus destruction, consistent with cocaine abuse. He was treated with antibiotics followed by dacryocystorhinostomy with silicone intubation. He had 2 recurrences of dacryocystitis and underwent one additional lacrimal surgery. CONCLUSIONS: Cocaine abuse and its accompanying intranasal and sinus destruction should be considered when determining the etiology of nasolacrimal obstruction and dacryocystitis. A medical and social history with specific questions about drug abuse may be useful. Computed tomography is helpful in delineating damage to the sinuses, nose and lacrimal system. Management with antibiotics and dacryocystorhinostomy surgery may result in resolution of symptoms.

Efficacy of mitomycin C in endoscopic dacryocystorhinostomy: a systematic review and meta-analysis.

BACKGROUND: A number of published comparative studies have been conducted to evaluate the efficacy and safety of intraoperative mitomycin C (MMC) in endoscopic dacryocystorhinostomy (EN-DCR). However, results have not always been consistent. Therefore, we carried out a meta-analysis to compare the clinical results of EN-DCR with and without MMC. METHODS AND FINDINGS: A comprehensive literature search of Cochrane Library, PubMed and EMBASE to identify relevant trials comparing EN-DCR with and without MMC. Eleven studies including 574 eyes were included in this meta-analysis. The success was defined as patency of the nasolacrimal canal and symptomatic improvement. There was significantly higher success rate in the MMC group in comparison with control group [RR = 1.12, 95% CI (1.04, 1.20), P = 0.004]. A sensitivity analysis after the non-randomized controlled trials were excluded from the meta-analysis demonstrated no differences compared with the overall results. Subgroup analyses showed that MMC group had a significantly higher success rate than control group in primary and revision EN-DCR, and EN-DCR without silicone intubation, but no difference in the subgroup of with silicone intubation. The size of the osteotomy site was bigger in the MMC group compared to the control group at 3 months [WMD = 7.65, 95% CI (0.33, 14.98), P = 0.041] and 6 months [WMD = 9.28, 95% CI (2.45, 16.11), P = 0.008] after surgery. However, there was statistically significant difference in the osteotomy surface area between the two groups at 12 months after surgery [WMD = 11.63, 95% CI (-1.04, 24.29), P = 0.072]. CONCLUSION: Intraoperative MMC application seems to be a safe adjuvant that could reduce the closure rate of the osteotomy and enhance the success rate after both primary and revision EN-DCR. TRIAL REGISTRATION: ClinicalTrials.gov NCT01772277.

A meta-analysis of primary external dacryocystorhinostomy with and without mitomycin C.

OBJECTIVE: To assess the efficacy and safety of local application of intraoperative mitomycin C (MMC) at the osteotomy site in primary external dacryocystorhinostomy (EX-DCR). METHODS: A comprehensive literature search of the Cochrane Library, PubMed and Embase was undertaken to identify relevant trials comparing EX-DCR with MMC (MMC group, from 0.2-1.0 mg/mL) and without MMC (control group). A total of nine randomized controlled trials (RCTs) were selected and a meta-analysis performed on the results of success rates, which were defined as patency of the nasolacrimal canal and symptomatic improvement. Statistical analysis was performed using RevMan 5.0 software. RESULTS: Nine RCTs reporting on a total of 562 DCRs including patients in the age range 30-57 years were included in the meta-analysis. However, the total number of males and females could not be determined as only four RCTs reported on this aspect. There was a significantly higher success rate in the MMC group in comparison with the control group (odds ratio, OR, 2.11; 95% confidence interval, CI, 1.19-3.74, P = 0. 01). In two RCTs, the mean osteotomy size 6 months postoperatively was significantly larger in the MMC group than in the control group (about 27mm(2) in the MMC group versus about 12mm(2) in the control group in the first study, and about 22mm(2) in the MMC group versus about 18mm(2) in the control group in the second study, P < 0.005). No intraoperative or postoperative complications except two cases with delayed healing of the external skin wound were recorded in the MMC group. CONCLUSION: Intraoperative MMC application seems to be a safe adjuvant that could reduce the closure rate of the osteotomy site after primary EX-DCR. Further well-organized, prospective, randomized studies involving larger patient numbers divided into subgroups for different concentrations of locally applied MMC are warranted.

Lacrimal drainage obstruction in gastric cancer patients receiving S-1 chemotherapy.

BACKGROUND: This study was conducted to determine the incidence and clinical characteristics of lacrimal drainage obstruction (LDO) in patients receiving S-1 chemotherapy. PATIENTS AND METHODS: Consecutive 170 patients with gastric cancer who underwent curative surgery and received adjuvant S-1 chemotherapy were enrolled. S-1 was administered orally (40 mg/m2 b.i.d. on days 1-28 every 6 weeks) for 1 year. Ophthalmologic examinations were carried out on patients complaining of epiphora. RESULTS: Thirty-one patients (18%) developed epiphora. Among 31 patients, 25 underwent ophthalmologic examinations and 22 (88%) were diagnosed with LDO. The median time to the onset of LDO was 2.9 months. The most common site of obstruction was the nasolacrimal duct [86% (19/22)]; punctal [23% (5/22)] and canalicular obstruction [14% (3/22)] were also noted. In multivariate analysis, total gastrectomy [versus partial gastrectomy: hazard ratio (HR), 2.9; P=0.014] and creatinine clearance<50 ml/min (versus ≥50 ml/min: HR, 2.9; P=0.038) were independent risk factors for the development of LDO. CONCLUSION: Considering the high incidence of LDO in patients receiving S-1 chemotherapy, oncologists should be alert to epiphora and cooperate with ophthalmologists in the early stages to improve the quality of life of patients and avoid more complicated ophthalmologic procedures.

Postoperative application of mitomycin-C in endocanalicular laser dacryocystorhinostomy.

PURPOSE: To determine the safety and efficacy of the multiple postoperative applications of mitomycin-C (MMC) after endocanalicular laser dacryocystorhinostomy. METHODS: Prospective interventional case series of 125 endocanalicular laser dacryocystorhinostomies using the diode laser. Mitomycin-C was placed intra-operatively in all cases. Application of MMC was also done postoperatively at 1 week, 2 weeks, and 3 weeks. The main outcome measure for success was resolution or improvement of epiphora, the patency of the osteum and the presence or absence of complications from the MMC application. Patients were followed up for at least 12 months. RESULTS: A total of 125 consecutive endocanalicular laser dacryocystorhinostomies on 114 patients (102 women, 12 men, mean age 60 years) were done from January 2002 to January 2005. The success rate at 12 months postoperatively was 92.8%. All failures were due to cicatricial closure of the osteum. No significant intra-operative and postoperative nasal complications from the MMC were recorded. CONCLUSION: Multiple postoperative applications of MMC appears to be a safe and effective adjunctive modality after endocanalicular laser dacryocystorhinostomy in primary acquired nasolacrimal duct obstruction.

Dacryoendoscopic observation and incidence of canalicular obstruction/stenosis associated with S-1, an oral anticancer drug.

PURPOSE: To report dacryoendoscopic observations and the incidence of lacrimal obstruction/stenosis associated with S-1, an oral anticancer drug. DESIGN: Retrospective, nonrandomized clinical trial. METHODS: A total of 52 patients (41 men, 11 women; age 42-93 years) who were prescribed the anticancer drug S-1 were studied. Patients who suffered eye complaints following S-1 treatment underwent ophthalmic examination, probing and lacrimal irrigation. Patients whose tear meniscus was high or had abnormal lacrimal irrigation were evaluated by dacryoendoscopy. RESULTS: Overall, 5 of 52 S-1-treated patients (9.6%) experienced lacrimal passage stenosis/obstruction. One patient had punctal stenosis, and four patients had canalicular obstruction/stenosis. The onset of epiphora ranged from 2 to 8 months (4.4 ± 2.2 months, mean ± SD) after the initiation of chemotherapy. CONCLUSIONS: Patients receiving S-1 treatment should be evaluated for potential lacrimal disorders, particularly canalicular obstruction/stenosis. Dacryoendoscopic observation is effective for the diagnosis of this side effect.

Effect of mitomycin C on success rate in dacryocystorhinostomy with silicone tube intubation and improper flaps.

PURPOSE: To assess the effect of mitomycin C on surgical success rate of dacryocystorhinostomy and silicone intubation in patients with improper flaps. METHODS: The study was a randomized clinical trial. The patients with indication for dacryocystorhinostomy surgery with silicone intubation (inappropriate lacrimal sac or nasal mucosal flaps during surgery and/or history of dacryocystitis in the past 3 months) were randomly assigned to application of mitomycin C (0.02%) on surgical flaps (group A) or a control group without mitomycin C application (group B). Main outcome measures were subjective symptomatic improvement and result of irrigation test at last follow-up visit. RESULTS: The study enrolled 88 patients (88 eyes); there were 42 patients in group A and 46 patients in group B. There was an average follow-up of 10 months (range 6-15 months) following surgery. Significant improvement (no tearing with patent lacrimal system in irrigation) was observed in 31 patients (73.8%) in group A and 32 patients (69.6%) in group B. There was no statistically significant difference in no improvement (no change in tearing state and obstruction in irrigation test), relative improvement (decreased tearing and passage of fluid with force in irrigation test), and significant improvement rate between the 2 groups of study (p>0.05). CONCLUSIONS: Application of mitomycin C on surgical flaps during dacryocystorhinostomy surgery with silicone intubation in patients with improper flaps has no proven beneficial effect on success rate of surgery.